Music Home Health

“Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient’s representative (if any), and the patient’s primary caregiver(s); This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence, rather than in a more traditional healthcare facility setting) ) failed to include emergency contact information on Patient Information (information that identifies the patient and details about health or treatment) sheet for two of four sampled patients (Patient 9 and Patient 11). This failure has a clinical impact on clinical records for inaccurate and incomplete information. a. During a review of Patient 9’s Patient Information, the Patient Information indicated that Patient 9 was admitted to the HHA on 3/8/2024 with a primary diagnosis of essential hypertension (a form of high blood pressure that is often due to obesity, family history and an unhealthy diet). On 9/5/2024 at 3:17 p.m. and 4:03 p.m., and on 9/6/2024 at 9:53 a.m., calls were made to Patient 9 at the listed contact number on the Patient Information sheet, but the calls were unanswered and unreturned. There was no emergency or alternate contact number listed. On 9/6/2024 at 12:15 p.m., the survey team requested the Chief Operating Officer (COO) of the HHA to contact Patient 9. The COO stated that Patient 9 did not answer the calls. When the survey team asked for an alternate contact number for Patient 9, the COO stated the telephone number on the Patient Information sheet was the only contact number the HHA had for Patient 9. During an interview with the COO on 9/6/2024 at 2 p.m., the COO stated he was not aware the HHA did not have the emergency or alternate contact numbers for Patient 9 and Patient 11. The COO stated it was important to list the emergency or alternate contact number for each patient, so the HHA would be able to contact the patient’s family member or representative in the event of an emergency. The COO stated the HHA would ensure that emergency contact was available for all patients. During a review of the undated HHA’s Policy and Procedure (P and P), titled “Contents of the Clinical Record,” the P and P indicated that the following information would be available in the clinical record: - Name and telephone number of family/caregiver and patient representative to be contacted in the event of an emergency/death. b. During a review of Patient 11’s Home Health Certification and Plan of Care (POC, a written document developed for each patient by the support team using a patient-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the patient) with the certification period from 5/26/2024 to 7/24/2024, the Home Health Certification and POC indicated Patient 11 has a start of care date of 3/27/2024 with a principal diagnosis of hypertensive (when the pressure of the patient’s blood vessels is too high) heart disease (disease that affects the heart or the blood vessels) without heart failure (occurs when the heart muscle does not pump blood as well as it should) and chronic kidney disease (kidneys slowly get damaged and unable to function normally like removing waste and keeping blood pressure normal), included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment including disease processes, signs and symptoms of exacerbation and potential complications and home management of medical condition. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. During a concurrent interview and record review on 9/6/2024 at 2 p.m. with the Home Health Agency’s Chief Operating Officer (COO), Patient 11’s Patient Information Sheet, undated, was reviewed. The Patient Information Sheet of Patient 11 indicated no emergency contact information or alternate contacts for Patient 11. The COO confirmed that there was no indicated formation of emergency contacts or alternate contacts in Patient 11’s Patient Information Sheet. The COO stated that it is not indicated in the Patient’s Information sheet but he presented Patient 11’s emergency plan sheet but there was also no indication of emergency contact information. The COO stated he was not aware the HHA did not have the emergency or alternate contact numbers for Patient 9 and Patient 11. The COO stated it was important to list the emergency or alternate contact number for each patient, so the HHA would be able to contact the patient’s family member or representative in the event of an emergency. The COO stated the HHA would ensure that emergency contact was available for all patients.”

“Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) regarding Patient Rights was met as follows: 1. The HHA failed to notify one out of seven sample patients, (Patient 3), regarding changes in the care when missed visits occurred. This deficient practice resulted to patient’s treatment care not provided and had the potential to affect the quality of life and wellbeing of the patient. (Refer to G 434). 2. The HHA failed to provide information on discharge planning for one out of seven sampled patients (Patient 3). (Refer to G452). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Comprehensive Assessment of Patients was met as follows: 1. The HHA failed to maintain an accurate, current medication profile for one of seven patients (Patient 4). Refer to G536. 2. The HHA failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) of the patient’s surgical wound and pain level was updated, for one of 7 sampled patients (Patient 4). (Refer to G544). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Comprehensive Assessment of Patients to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) for Care Planning, Coordination, Quality of Care was met as follows: 1. Based on interview and record review, the home health registered nurse failed to develop a written plan of care in consultation with the physician for one out of seven sampled patients (Patient 3). (Refer to G572). 2. Based on interview and record review, the Home Health Agency (HHA) failed to provide services as ordered by the physician for one out of seven sampled patients (Patient 3). (Refer to G580). 3. Based on interview and record review, the skilled nurse (SN) failed to notify the physician regarding the plan to discharge the patient from home health services for one out of seven sampled patients (Patient 3). (Refer to G590). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients certified to receive home health services.”

“Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA’s policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This Standard is not met as evidenced by: Based on interview and record review, the HHA (home health agency) failed to provide information on discharge planning for one out of seven sampled patients (Patient 3). This deficient practice had the potential that patient’s rehabilitative needs will not be provided and can affect in maintaining the highest practicable physical, mental, and psychosocial wellbeing of the patient. On 1/5/2024, at 3 p.m., a complaint validation survey was conducted at the home health agency (HHA) regarding a complaint that Patient 3 was not provided skilled nurse (SN) and physical therapy (PT) services he needed after being discharged from the general acute care hospital (GACH) for rehabilitation purposes and was not informed of any changes in the care to be provided by the HHA. On 1/5/2024, at 4 p.m., during an interview with Complainant 1, Complainant 1 stated Patient 1 told her that RN 1 (registered nurse) made an initial al visit on 8/14/23, and before RN 1 left, she told Patient 1 she will come back in three days but two weeks have passed and there was no visit, nor a phone call made the HHA to inform Patient 3. A review of Patient 3’s Physician Admission referral order dated 8/10/23, indicated the patient was discharged from an acute hospital with a referral to admit to HHA for SN adherence and PT evaluation/treatment. A review of Patient 3’s Patient Consent for Treatment dated 8/15/23, indicated the patient signed an agreement of accepting HHA’s treatment/services. During a review of Patient 3’s face sheet indicated a start of care (SOC) date of 8/14/23, with a diagnosis that includes left knee osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of Patient 3’s initial Outcome and Assessment Information Set (OASIS) date 8/14/23, indicated the patient had memory deficits, inability to recall events of past 24 hours and had the ability to walk with the use of one-handed device, however specific assistive device used was not identified. A review of Patient 3’s Discharge Summary note dated 8/29/23, indicated that Patient 3’s wife called the HHA and was very upset because Patient 3 did not receive PT or SN visits. Patient 3 told the HHA that the patient did not want the HHA services anymore and would look somewhere that could provide the services. HHA did not have a document to prove Patient 3 was assisted with discharge planning. On 1/7/2024, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated RN 1 did her initial visit on 8/14/23, at Patient 3’s residence. After the visit, RN 1 reported to the HHA that she was not coming back to see Patient 3 anymore because it was not safe to drive at the patient’s home location due to the house was located in the middle of nowhere on a dirt road (unpaved road). DPCS also stated that the HHA tried to look for other agencies to handle the patient’s care and the HHA was in contact with the patient’s insurance letting them know about the issue of unable to provide care for Patient 3. When the DPCS was asked if the patient and family were notified of the inability of the agency to provide the home health services, she stated the HHA staff notified the patient, and he was aware of it. Further review of Patient 3’s clinical record indicated no documented evidence the HHA notified the patient regarding Patient 3’s discharge. Record review indicated Patient 3 was discharged on 8/29 /2023 as indicated in the discharge summary and was not provided the services ordered in the referral physician’s orders. A review of the HHA’s undated policy and procedure “Discharge Planning”, indicated that patients will not be discharged without appropriate preparation. The patient’s continuing care needs will be assessed on an ongoing basis, as well as at discharged. Information will be provided to assist the patient in planning his/her discharge, including referral and transfers.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure the comprehensive assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services) of the patient’s surgical wound and pain level was updated, for one of 7 sampled patients (Patient 4). This deficient practice had the potential that patient’s care needs will not be identified and provided timely interventions and could lead to poor and delayed healing of the surgical wound. A review of Patient 4’s Patient Profile indicated, a start of care (SOC) date of 6/29/2023, with a diagnosis that included unilateral primary osteoarthritis (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints and cause pain. During a review of Patient 4’s Plan of Care (POC), for the re-certification period from 12/26/2023 to 2/23/2024 included an order for skilled nurse (SN) to visit once for evaluation only and physical therapy (PT) evaluation and treatment plan. On 1/6/2024, at 10:15 a.m., a home visit was conducted at Patient 4’s residence with Licensed Vocational Nurse (LVN 1). Patient 4 was observed sitting on a chair in the living room with her right leg elevated on a stool. Complained of severe pain on the right leg. Patient 4 had a surgical dressing from the knee down to her shin. Walked using a four-wheel walker. Patient 4 was alert and oriented to name, place, and person. LVN 1 proceeded to administer care. During a concurrent interview with Patient 4 on the same date and time, Patient 4 stated that her Physical therapy was placed on hold for 6-7 weeks before her scheduled knee surgery last 12/26/2023. Patient 4 stated that since then there was no physical therapy. Patient 4 also stated that she has a follow appointment up with her doctor on Tuesday 1/9/2024 and will ask when she can continue physical therapy. A request was made to the Director of Nursing (DON) and Administrator (Admin) for evidence of the wound assessment and physical therapy orders for Patient 4’s recertification. There was no evidence or an updated surgical wound care order, no physical therapy order written for the recertification. There were physical therapy notes, however there was no re-evaluation to resume physical therapy. During a joint interview with the administrator (Admin) and the Director of Nursing (DON) on 1/7/2024, at 11:30 a.m., the DON was asked if PT re-evaluation was performed before resuming PT services. Both Admin and DON stated they do not have it in the assessment. Admin stated the agency was currently in the process of reorganizing the company. DON stated that there were no pictures of the patient’s surgical wounds. DON was asked how she could follow up if the wound was getting better, she stated she just rely on the nurse’s documentation. During a review of the HHA’s undated policy and procedure (P&P) titled “ Wound Care Management: Documentation Guidelines”, the P&P indicated to document in the clinical record:a. Incision characteristics and any bleeding, drainage, or wound separation.b. Number of staples removed.c. The client’s tolerance of the procedure. Assess wound characteristics, size, and appearance. During a review of the HHA’s undated P&P titled “ Contents of the Clinical Record”, the P&P indicated that a clinical record will be maintained for each patient receiving care. The clinical record contains sufficient information to identify the patient, describe the patient’s problems, needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the home health registered nurse failed to develop a written plan of care in consultation with the physician for one out of seven sampled patients (Patient 3). This deficient practice resulted in the delay to identify and implement the patient care needs for services, treatment, and intervention affecting the patient’s health status and wellbeing. On 1/5/2023, at 3:00 p.m., a complaint validation survey was conducted at the HHA. On 1/5/2023, at 4:00 p.m., during an interview with Complainant 1, the Complainant 1 stated Patient 1 told her that registered nurse (RN 1) made an initial visit on 8/14/2023, and before RN 1 left, she told Patient 1 she will come back in three days, but two weeks have passed and there was no visit, nor a phone call made by the HHA staff. A review of Patient 3’s Physician Admission referral order dated 8/10/2023, indicated Patient 3 was discharged from an acute hospital with a referral to admit to HHA for skilled nursing (SN) services for medical adherence that included compliance to medical device, drug or medication compliance, medical devise use, selfcare, self-directed exercises or therapy sessions, and physical therapy (PT) evaluation/treatment. A review of Patient 3’s Patient Consent for Treatment dated 8/15/2023, indicated Patient 3 signed an agreement of accepting HHA’s treatment/services. During a review of Patient 3’s Face Sheet indicated a start of care (SOC) date of 8/14/2023, with a diagnosis that included left knee osteoarthritis (type of arthritis that occurs when flexible tissue at the end of the bones wear down). A further review of Patient 3’s clinical record, indicated no documented evidence a written plan of care was developed for the patient in consultation with the physician. On 1/7/2024, at 12:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated there was no plan of care developed for this patient because she was not legally admitted patient to receive their services. A review of the HHA’s undated policy and procedure “ Admission Criteria and Process”, indicated if the patient is accepted for home health, an initial plan of care will be developed in consultation with the physician and the patient.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the HHA (home health agency) failed to notify one out of seven sample patients, (Patient 3), regarding changes in the care when missed visits occurred. This deficient practice resulted to patient’s treatment care not provided and had the potential to affect the quality of life and wellbeing of the patient. On 1/5/2024, at 3 p.m., a complaint validation survey was conducted at the home health agency (HHA) regarding a complaint that Patient 3 did not get the skilled nurse (SN) and physical therapy (PT) services he needed after being discharged from a general acute care hospital (GACH) for rehabilitation purposes and was not informed of any changes in the care to be provided by the HHA. On 1/5/2024, at 4 p.m., during an interview with Complainant 1, the Complainant 1 stated Patient 3 told her that a registered nurse (RN 1) made an initial visit on 8/14/23, and before RN 1 left, she told Patient 1 she will come back in three days, but two weeks had passed and there was no visit, nor a phone call made by RN 1 to inform Patient 1 of the missed visits. During a review of Patient 3’s “Physician’s Admission” referral order dated 8/10/23, the referral order indicated Patient 3 was discharged from GACH with a referral to admit to HHA for SN services for medical adherence that included compliance to medical advice, drug or medication compliance, medical device use, selfcare, self-directed exercises or therapy sessions. PT services (physical therapy) to perform initial evaluation and treatment. A review of Patient 3’s “Patient Consent for Treatment” dated 8/15/23, indicated the patient signed an agreement accepting HHA’s treatment/services. During a review of Patient 3’s face sheet indicated a start of care (SOC) date of 8/14/23, with a diagnosis that included left knee osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). A review of Patient 3’s initial Outcome and Assessment Information set (OASIS-a standardized assessments used in Medicare home health care to plan care, determine reimbursement, and measure quality) dated 8/14/23, indicated the Patient 3 had memory deficits, inability to recall events of past 24 hours and had the ability to walk with the use of one-handed device, however the specific assistive device to be used was not identified. A review of Patient 3’s Discharge Summary note dated 8/29/23, indicated that Patient 3’s wife called the HHA and was very upset because Patient 3 did not receive PT and/or SN visits. The patient’s wife further told the HHA staff, Patient 3 did not want the HHA services anymore and would look somewhere else that could provide the needed services. On 1/7/2024, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated RN 1 did the initial visit on 8/14/23 at Patient 3’s residence. After the visit, RN 1 reported to the HHA that she was not coming back to see Patient 3 anymore because it was not safe to drive at the patient’s home location due to the house was located in the middle of nowhere on a dirt road. DPCS also stated that the HHA tried to look for other agencies to handle the patient’s care and the HHA was in contact with the patient’s insurance letting them know about the issue of the agency’s inability to provide home care for Patient 3. DPCS was asked if the patient and family were notified of the agency’s inability to provide the physician’s referral order for home health services to Patient 3, the DPCS stated the HHA notified Patient 3 and he was aware of it. Further review of Patient 3’s clinical record indicated no documented evidence the HHA staff notified the patient regarding the inability to provide home health services as referred by the physician. There was no documented evidence the referring physician was notified of the agency staff’s inability to provide the services. A review of the HHA’s policy and procedure “Admission Criteria and Process”, indicated once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission and applicable laws and regulations.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain an accurate, and current medication profile for one of seven patients (Patient 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions that could impact the health and safety of the patient. A review of Patient 4’s Patient Profile indicated, a start of care (SOC) date of 6/29/2023, with a diagnosis that included unilateral primary osteoarthritis (caused by the breakdown of cartilage, a rubbery material that eases the friction in the joints, and cause pain). During a review of Patient 4’s Plan of Care (POC), for the re-certification period from 12/26/2023 to 2/23/2024 included an order for skilled nurse (SN) to visit once for evaluation and physical therapy (PT) evaluation and treatment plan. On 1/6/2024, at 10:15 a.m., a home visit was conducted at Patient 4’s residence with Licensed Vocational Nurse (LVN 1). Patient 4 was observed sitting on a chair in the living room with her right leg elevated on a stool (seat). Patient 4 complained of severe pain on the right leg. Patient 4 had a surgical dressing from the knee down to her shin. Patient 4 ambulated using a four-wheel walker. Patient 4 was alert and oriented to name, place and person. LVN 1 proceeded to administer care. During a review of Patient 4’s medications on 1/6/2024, at 11 a.m., multiple medication discrepancies were noted on the medication profile: Hydrochlorothiazide 2.5 mg (milligram- unit of measurement) was listed. On the medication bottle and patient personal medication list, it indicated Hydrochlorothiazide 25 mg daily for hypertension and swelling. Metformin 1000 mg 1 tab daily was listed, but on bottle it was indicated twice daily for diabetes. Aspirin 325 mg 1 tab daily to be taken for 2 weeks after surgery on 12/26/2023. Amlodipine 10 mg daily was increased to 5 mg in the morning and 10 mg at night. Ibuprofen 800 mg 1 tab daily was increased to every 8 hours for knee pain. New order of Norco 10/325 mg every 6 hours as needed for pain after surgery started 12/26/2023. Naproxen 00 mg 1-2 times a day for pain was not included in the medication list. During a concurrent interview with Patient 4 on the same date and time, Patient 4 stated that she had knee surgery last 12/26/2023 and was prescribed these medications. Patient 4 stated that her pain level was a “20”/10 (numerical scale from 0-10, with pain level of 0-5 no pain to moderate pain, 6-10 moderate to severe pain) very severe pain. Patient 4 stated that she had been on constant pain after the surgery and the cold weather. Patient 4 stated she takes all these pain medications to subside her pain and swelling. During a concurrent interview on the same date and time with LVN 1, LVN 1 stated that she was not the regular nurse that visited Patient 4 and stated she will call and inform the office the next business day to be referred to the doctor. LVN 1 stated it was important to have a complete and accurate medication profile upon admission and should be checked every home visit. During a review of the HHA’s undated policy and procedure (P&P) titled “Complete Medication Orders”, the (P&P) indicated medications identified during the initial assessment visit and throughout the certification period are documented on the initial and recertification plans of care, as well as in the clinical visit note and the Medication Profile. Medication order changes should be documented on a physician verbal/telephone order form, the patient’s medication record and in the visit note as applicable.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide services as ordered by the physician for one out of seven sampled patients (Patient 3). This deficient practice resulted in the delay to provide and implement care services, treatment, and intervention that could affect the patient’s health status and wellbeing. On 1/5/2023, at 3:00 p.m., a complaint validation survey was conducted at the HHA. On 1/5/2023, at 4:00 p.m., during an interview with Complainant 1, the Complainant 1 stated Patient 1 told her that Registered Nurse (RN 1) made an initial visit on 8/14/2023, and before RN 1 left, she told Patient 1 she will come back in three days, two weeks had passed and there was no visit, nor a phone call made by the HHA staff to inform Patient 3. A review of Patient 3’s Physician Admission referral order dated 8/10/2023, indicated Patient 3 was discharged from an acute hospital with a referral to admit to HHA for skilled nursing (SN) services for medical adherence that included compliance to medical device, drug or medication compliance, medical devise use, selfcare, self-directed exercises or therapy sessions, and physical therapy (PT) evaluation/treatment. A review of Patient 3’s Patient Consent for Treatment dated 8/15/2023, indicated Patient 3 signed an agreement of accepting HHA’s treatment/services. During a review of Patient 3’s Face Sheet, indicated a start of care (SOC) date of 8/14/2023, with a diagnosis that included left knee osteoarthritis (type of arthritis that occurs when flexible tissue at the end of the bones wear down). A review of Patient 3’s Initial Outcome and Assessment Information Set (OASIS, a comprehensive assessment to collect and report quality data to Centers for Medicare and Medicaid Services [CMS]), dated 8/14/2023, indicated Patient 3 had memory deficit, inability to recall events of past 24 hours, and had the ability to walk with the use of one-handed device, however, the type of assistive device was used was not identified. A review of Patient 3’s Discharge Summary note dated 8/29/2023, indicated that Patient 3’s wife called the HHA and was very upset because Patient 3 did not receive PT or SN visits. The note indicated Patient 3’s wife told the HHA that the patient did not want the HHA services anymore and would look for another agency that could provide the services. On 1/7/2023, at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPSC stated RN 1 did her initial visit on 8/14/2023, at Patient 3’s residence. After the visit, RN 1 reported to the HHA that she was not coming back to see Patient 3 anymore because it was not safe to drive at the patient’s home location due to the house was located in the middle of nowhere on a dirt road (unpaved road). The DPCS stated that the HHA tried to look for other agencies to handle the patient’s care and the HHA was in contact with the patient’s insurance to let them know about the issue of unable to provide care to Patient 3. A review of the HHA’s undated policy and procedure “Physician Participation in Plan of Care”, indicated the care will be provided in compliance with therapeutic and diagnostic orders and accepted standards and practice.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the skilled nurse (SN) failed to notify the physician of the agency’s plan to discharge the patient from home health services for one out of seven sampled patients (Patient 3). This deficient practice resulted in the patient’s care needs not met affecting the patient’s health status and wellbeing. On 1/5/2023, at 3:00 p.m., a complaint validation survey was conducted at the HHA. On 1/5/2023, at 4:00 p.m., during an interview with the Complainant 1, the Complainant 1 stated Patient 1 told that registered nurse (RN 1) made an initial visit on 8/14/2023, and before RN 1 left, she told Patient 1 she will come back in three days, but two weeks had passed and there was no visit, nor a phone call made by the HHA staff to inform Patient 3. A review of Patient 3’s Physician Admission referral order dated 8/10/2023, indicated Patient 3 was discharged from an acute hospital with a referral to admit to HHA for skilled nursing (SN) services for medical adherence that included compliance to medical device, drug or medication compliance, medical devise use, selfcare, self-directed exercises or therapy sessions, and physical therapy (PT) evaluation/treatment. A review of Patient 3’s Patient Consent for Treatment dated 8/15/2023, indicated Patient 3 signed an agreement of accepting HHA’s treatment/services. During a review of Patient 3’s Face Sheet indicated a start of care (SOC) date of 8/14/2023, with the diagnosis that included left knee osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wear down). A review of Patient 3’s initial Outcome and Assessment Information Set (OASIS) dated 8/14/2023, indicated Patient 3 had memory deficit, inability to recall events of past 24 hours, and had the ability to walk with the use of one-handed device, however, the note did not specify the type of assistive device was used. A review of Patient 3’s Discharge Summary note dated 8/29/2023, indicated that Patient 3’s wife called the HHA and was very upset because Patient 3 did not receive PT or SN visits. Patient 3’s wife told the HHA that the patient did not want the HHA services anymore and would look for another agency that could provide the services. On 1/7/2023, at 11:00 a.m., during an interview with the DPCS, the DPCS stated RN 1 did her initial visit on 8/14/2023, at Patient 3’s residence. After the visit, RN 1 reported to the HHA that she was not coming back to see Patient 3 anymore because it was not safe to drive at the patient’s home location due to the house was located in the middle of nowhere on a dirt road (unpaved). The DPCS stated that the HHA tried to look for other agencies to handle the patient’s care and the HHA was in contact with the patient’s insurance to let them know about the issue of unable to provide care to Patient 3. When the DPCS was asked if the physician was notified of changes of care being provided to Patient 3, the DPCS stated the physician was made aware of it. A further review of Patient 3’s clinical record indicated no documented evidence the HHA notified the physician regarding the plan to discharge Patient 3. A review of HHA’s undated policy “Change of Condition (undated),” indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient’s condition. A review of HHA’s undated policy “Care Planning Process (undated),” indicated clinicians will inform the patient’s physician of any changes that suggest a need to later the plan of care.”